Wie lange dauert es, einen Chirurgen zu trainieren?

Crunch time for doctors’ hours
Fiona Godlee, editor, BMJ
fgodlee@bmj.com
Concern about the European Working Time Directive continues to run high, and its effects on patient care and specialist training remain hotly disputed. Fewer hours a week and fewer years in training presage a cohort of less experienced new consultants. A shortage of doctors in the UK means juniors doing unpaid or additional locum work to fill rotas and having to lie about their hours (http://careers.bmj.com/careers/advice/view-article.html?id=20000485). Shift systems, loss of the team structure, and poor handover are also reported to be damaging morale.
The strongest protests come from the surgeons, who are especially vulnerable to the effects of reduced hands-on experience. So we asked a former member of our editorial advisory board, Gretchen Purcell Jackson, herself a paediatric surgeon in Nashville, to tell us how long it takes to train a surgeon. She and John Tarpley (doi:10.1136/bmj.b4260) cite evidence suggesting that the 80 hour week imposed across the USA in 1993 reduced the quality and quantity of residents’ operative experience. Nevertheless, the US Institute of Medicine recently called for further reductions in working hours.
Evidence from educational psychologists suggests that to acquire elite levels of expertise—whether in music, athletics, or science—requires about 10 000 hours of practice. Given the need for surgeons to master both cognitive and manual skills, our authors say this number should be doubled, requiring an 80 hour week through a five year residency programme. They say that if trainees can’t get enough experience during a restricted working week, surgical training should be extended.
Eighty hours is already out of sight for surgical trainees in Europe, no doubt to the cheers of some who survived the old regime and more who didn’t. But the concerns about loss of experience are real. In a recent Royal College of Surgeons survey (http://careers.bmj.com/careers/advice/view-article.html?id=20000443), two thirds of respondents thought quality of care had worsened and more than half believed that patient safety was threatened. Countering these concerns was a recent survey by the Postgraduate Medical Education and Training Board (http://careers.bmj.com/careers/advice/view-article.html?id=20000423), which found that juniors in posts that complied with the directive were less likely to repor t errors.
Surveys are important but, as Andrew Goddard of the Royal College of Physicians said in a recent letter (BMJ 2009;338:b1815, doi:10.1136/bmj.b1815), they aren’t going to sway MPs to call for a change in the law. What we need is hard evidence of effects on patient care. In its absence, and given the legislative deadlock that surrounds the directive (BMJ 2009;338:b1507, doi:10.1136/bmj.b1507) we shouldn’t expect a new law anytime soon.
Can we live with what we’ve got? Roy Pounder, not a surgeon but deeply versed in the EWTD, thinks that surgeons can get their 65 hour week under the current law through more flexible rostering (doi:10.1136/bmj.b4488). And there is hope from Holland, where surgeons apparently have managed fewer hours through a mix of flexibility, smarter working, structured training, and non-trainee posts for routine work (BMJ 2008;337:a1775, doi:10.1136/bmj.a1775). With such models before us, why can’t we achieve clinical excellence at far less personal cost?
Cite this as: BMJ 2009;339:b4569